- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.78 / $3,372.66 / $3,372.66
| Professional | | $738.78 | $3,372.66 | $3,372.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.56 / $1,040.56 / $1,040.56
| Facility | | $1,040.56 | $1,040.56 | $1,040.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.50 / $1,040.56 / $1,040.56
| Professional | | $669.50 | $1,040.56 | $1,040.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.56 / $1,082.90 / $1,158.10
| Facility | | $1,040.56 | $1,082.90 | $1,158.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.05 / $898.27 / $1,372.00
| Professional | | $634.05 | $898.27 | $1,372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.71 / $1,135.81 / $1,816.68
| Professional | | $889.71 | $1,135.81 | $1,816.68 |